论文部分内容阅读
病历档案一般简称为病案,记录了患者疾病的发生、发展、治疗经过及其结果等,是医疗机构医疗信息的基本载体,属医药卫生科技档案,是国家档案的重要部分。随着医疗卫生体制改革的不断深化,病历档案的价值日益凸显,它不仅可为医院科学、教学、医疗质量评估、医疗统计、医院管理等院的病措历施档成刚
Medical records are generally referred to as medical records, recording the occurrence, development, treatment and the results of the patient’s diseases. It is the basic carrier of medical information of medical institutions and belongs to the medical and health science and technology files. It is an important part of the national archives. With the continuous deepening of the medical and health system reform, the value of the medical records has become increasingly prominent. It not only can be used as a tool for hospital science, teaching, medical quality assessment, medical statistics, and hospital management